Case Report Multidisciplinary Management of Complicated ...Multidisciplinary Management of Complicated Crown-Root Fracture of an Anterior Tooth Undergoing Apexification ... time spent

Case ReportMultidisciplinary Management of Complicated Crown-RootFracture of an Anterior Tooth Undergoing Apexification

Merve Mese,1 Merve Akcay,1 Bilal Yasa,2 and Huseyin Akcay3

1Department of Pedodontics, Faculty of Dentistry, University of Izmir Katip Celebi, 35640 Izmir, Turkey2Department of Restorative Dentistry, Faculty of Dentistry, University of Izmir Katip Celebi, 35640 Izmir, Turkey3Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Izmir Katip Celebi, 35640 Izmir, Turkey

Correspondence should be addressed to Merve Akcay; [email protected]

Received 17 April 2015; Accepted 27 May 2015

Academic Editor: Stefan-Ioan Stratul

Copyright © 2015 Merve Mese et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The purpose of this case report was to present the multidisciplinary management of a subgingival crown-root fracture of a patientundergoing apexification treatment. A 12-year-old male patient was referred to the pediatric dentistry clinic with an extensivetooth fracture of the right permanent maxillary lateral incisor. Clinical and radiographic examinations revealed the presenceof a complicated crown-root fracture, which had elongated to the buccal subgingival area. The dental history disclosed that theapexification procedure had been started to be performed after his first trauma experience and he had neglected his appointment.The coronal fragment was gently extracted; endodontic treatment was performed; flap surgery was performed to make the fractureline visible.The coronal fragment was reattached to the root fragment with a dual-cure luting composite. A fiber post was stabilizedand the access cavity of the tooth was restored with composite resin. At the end of the 24th month, the tooth was asymptomatic,functionally, esthetically acceptable and had no periapical pathology. It is important for the patients undergoing apexificationtreatment to keep their appointments because of the fracture risk. Restoration of the fractured tooth by preparing retention groovesand a bonding fiber-reinforced post are effective and necessary approaches for successful management.

1. Introduction

The treatment of a pulpal injury of immature teeth createstechnical difficulties for endodontic treatment, and a root-end closure (apexification) procedure is usually requiredto induce a calcified barrier in an open apex. Patientsundergoing apexifications treatment have high crown-rootfracture risks because of the thin dentinal walls [1, 2].

A permanent tooth suffering from trauma could be aconsiderable problem especially for young patients owing tofunctional and esthetic causes [3, 4]. A complicated crown-root fracture is a type of traumatic dental injury that involvesthe enamel, dentin, and cementum. This type of fractureusually results from a horizontal impact [5]. Crown-root frac-tures may be classified as complicated, due to pulpal involve-ment, which are more frequent, or noncomplicated, whichhave an absence of pulpal involvement [6, 7]. Crown-rootfractures are quite common and frequently present treatment

problems due to the complex nature of the injury [8]. Toperform optimal treatment in such cases it is necessary to usethe combined efforts of an interdisciplinary approach, whichinvolves representatives from pediatric dentistry, endodon-tics, oral surgery, orthodontics, and restorative dentistry [9,10].

The aim of this case report was to present the multidis-ciplinary management of a complicated crown-root fracturethat extended subgingivally in an anterior tooth.

2. Case Report

A 12-year-old male patient was referred to the pediatricdentistry clinic at theUniversity of Izmir Katip Celebi Facultyof Dentistry complaining of a tooth fracture after biting intochocolate.

The clinical examination revealed a complicated crown-root fracture of the right permanent maxillary lateral incisor

Hindawi Publishing CorporationCase Reports in DentistryVolume 2015, Article ID 521013, 5 pageshttp://dx.doi.org/10.1155/2015/521013

2 Case Reports in Dentistry

(a) (b)

(c) (d) (e)

Figure 1: (a) Intraoral buccal view of a crown-root fracture. (b) Intraoral occlusal view of a crown-root fracture. (c) Preoperative intraoralradiograph showing the extension of the fracture. (d) View of the remaining root fragment after the removal of the coronal fragment. (e)View of the extracted coronal fragment.

with a mobile coronal tooth fragment that extended subgin-givally in the buccal area (Figures 1(a)-1(b)). A radiographicexamination showed that residual calcium hydroxide pasteexisted in the root canal and the fractured tooth had amature apex (Figure 1(c)). The patient’s medical history wasnoncontributory. The patient’s dental history disclosed thatthe patient had suffered dental trauma without any fracturenearly 18 months earlier. An apexification procedure hadstarted to be performed at that time, but the patient neglectedhis appointment for about 12 months. Because of the thin andfragile root wall, the tooth was fractured 11 months after hislast appointment.

A temporary restoration was present on the coronaltooth fragment and part of the coronal fragment was mobileand attached to the gingiva. Under local anesthesia, thecoronal fragment was gently extracted (Figures 1(d)-1(e)).Because of the completion of calcification of the apical rootarea, endodontic treatment was planned during the sameappointment.

After preparing an endodontic access cavity, the rootcanal working length was determined to be 20mm with

a periapical radiograph. Due to the overcalcification of theapical root area, the root canal length was determined to be2mm shorter. Using endodontic K-files and H-files, shapingand cleaning of the root canal were performed. After the canalpreparation, gutta-percha cones (Meta-Biomed, Cheongwon,Korea) were then lightly coated with an epoxy resin-basedsealer (AH Plus Jet, Dentsply DeTrey, Konstanz, Germany)and the root canal treatment was completed with a lateralcondensation. Subsequent to the canal obturation, a flapsurgery was performed tomake the fractured root face visible(Figure 2(a)). Hemorrhage was reduced by the applicationof an adrenaline-soaked gauze with pressure. A retractioncord impregnated with 25% aluminum chloride retractionsolution (Viscostat Clear, Ultradent, South Jordan, UT, USA)was placed on the fractured tooth borderline to control thesulcular hemorrhage (Figure 2(b)).

At the same time, retention grooves were created on thecoronal fragment with a round diamond bur (Figure 2(c)),and acid etching (Vococid, Voco, Cuxhaven, Germany) wasapplied to the enamel of the coronal fragment. After hem-orrhage control, a thin adhesive system (Clearfil SE Bond,

Case Reports in Dentistry 3

(a) (b) (c)

(d) (e) (f)

(g) (h)

Figure 2: (a) Exposing the fracture line surgically. (b) Retraction cord application. (c) Grooves created on the coronal fragment. (d)Reattachment of the coronal fragmentwith a dual-cure luting composite. (e) Checking the adaptation of the resin fiber post into the root canal.(f) Intraoral view of the 1-week follow-up exam after reattachment. (g) Intraoral view of the 24-month follow-up exam after reattachment.(h) Periapical radiograph of the 24-month follow-up exam showing no pathologic alteration. Notice the grooves in the coronal fragment(arrows).

Kuraray, Osaka, Japan) was applied to both the coronal androot fragments. By using a dual-curing luting composite(Variolink N, Ivoclar, Vivadent, Schaan, Liechtenstein), thecoronal fragment was reattached to the root fragment andthen polymerized (Figure 2(d)). The flap was then reap-proximated to its original position and esthetically sutured(Figure 2(e)).

The root canal obturationwas removedwith drills to placea fiber post into the root canal for supporting the coronalfragment. The post space was etched and an adhesive system(Syntac, Ivoclar) of luting composite was applied. We thenperformed a 9% hydrofluoric acid etching and silanization(Porcelain Etch and Silane, Ultradent, South Jordan, UT,USA) of the post, which was a size #2 glass fiber post witha 1.4mm diameter (Cytec Blanco, Hahnenkratt, Konigsbach-Stein, Germany). The post was placed at the length of 11mmand was stabilized into the canal with a dual-curing lutingcomposite (Variolink N, Ivoclar) (Figure 2(e)). After cutting

the excessive post, access to the tooth was restored with acomposite resin (Clearfil Majesty, Kuraray, Okayama, Japan).After finishing and polishing, the restoration was checkedradiographically for occlusal interferences. Oral hygieneinstructions were given to the patient and a soft food diet wasadvised.

The patient was recalled at 1 week, 1 month, 12 months,and 24months after the treatment for follow-up examination.At the end of the follow-up visits, the clinical and radi-ological investigation of the tooth revealed that the toothwas asymptomatic, functional, and esthetically acceptablewith no evident clinical signs and no periapical pathology(Figures 2(f)–2(h)).

3. Discussion

Apexification is a reasonable treatment for teeth with openapices and nonvital pulp. Calcium hydroxide apexification

4 Case Reports in Dentistry

remains the most widely used technique for treatment ofthese teeth.However, the traditional use of calciumhydroxideto accomplish apexification has some disadvantages: (i) thereis a requirement for multiple visits over a lengthy time period(average 12 months) [11] and (ii) the calcium hydroxide hasbeen shownboth in clinical studies [1, 12] and in experimentalstudies [13, 14] to lead to a weakening of the root structure,often resulting in cervical root fractures [15]. In the presentstudy, the management of a fracture complication of ananterior tooth undergoing apexification was presented.

For cases of complicated crown-root fractures, there areseveral proposed treatment options including amucogingivalflap, an osteotomy/osteoplasty, and orthodontic or surgicalextrusion followed by the reattachment of the original frag-ment. Another option includes the restoration of the toothcrown with a restorative material or prosthetic rehabilitationof the tooth depending on the location of the fracture line[16–20]. If the fracture fragment is available, reattachmentshould be the first choice of treatment [21, 22]. As describedin previous studies [23–25], this case report shows thatthe adhesive reattachment of the original fragment offers aconservative, esthetic, and cost-effective restorative option.Furthermore, it is an acceptable alternative to resin-basedcomposite restorations for restoring esthetics and functionof obliquely fractured teeth. Reattachment of an autogenoustooth fragment also has the advantage of biological width,which is the sum of the epithelial and connective tissueattachment lengths [26].

Some reattachment techniques, such as direct reattach-ment of the fragment, internal enamel groove, internal denti-nal groove, and external enamel groove in a V-shape, havebeen used with better results when compared with the directreattachment of the fragments [27–29]. Previous studies indi-cated that the reattachment of the fractured fragment withoutany preparation of the coronal or root fragments resultsin lower bonding values [29, 30]. In this case, an internaldentinal groove was prepared on the coronal fragment toprovide a higher mechanical strength and longevity.

To reinforce the cervical level of the reattached tooth,it is recommended to use an intracanal post since theseinterlock the coronal and root fragments and also minimizethe stress on the reattached tooth fragment [31–33]. It hasbeen suggested that the use of a long, thin fiber post iseffective for reducing tensile stress that can lead to tooth rootfractures of the anterior teeth with endodontic treatments[34]. In the present case, the fracture line was extendingsubgingivally and the tooth was pulpless. Hence, it wasdecided to gain intraradicular retention by using fiber posts.

4. Conclusion

Crown-root fractures localized in the anterior region needto be evaluated from several perspectives including toothvitality, tissues involved, fracture location, and the quantityof remaining tooth structure. In the present case, mul-tidisciplinary adhesive surgical approaches provided goodresults in terms ofmaintaining the tooth’s structural integrity.Furthermore, a fragment reattachment of the tooth with a

complicated crown-root fracture with an intracanal fiber postsystem proved to be clinically successful after treatment.

Disclosure

Theauthors deny any financial affiliations related to this studyor its sponsors.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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Case Report Multidisciplinary Management of Complicated ...Multidisciplinary Management of Complicated Crown-Root Fracture of an Anterior Tooth Undergoing Apexification ... time spent